SOCIAL DEVELOPMENTAL HISTORY



Joint Educational Services in Special Education

REEVALUATION SOCIAL AND DEVELOPMENTAL HISTORY

(To determine eligibility under a different or additional category this form must be used. For other reevaluations this form is optional)

Student’s Name __________________________________________________________ STN ________________________________

Birthdate_________________________________Age____________________ Sex (circle one): Male Female

Home Address_____________________________________________________________ Phone________________________________

School ________________________________________________________________ Grade___________________________________

Person completing this form: (Circle one): Natural Mother, Natural Father, Foster Parent, Stepmother, Stepfather, Adoptive Parent or Other (Please explain):__________________________________________________________________________________________

Marital status of biological parents: __________________________________________________________________________________

If separated or divorced, how old was child at separation ___________________________ at divorce______________________________

Who has custody of this child? ____________________________ Does the child have contact with the non-custodial parent? __________

How often does the non-custodial parent see this child? (Circle one): At least Weekly, Monthly, Few times each Year, or Never

Is either biological parent deceased? Mother______________ Father_____________ If Yes, indicate the year______________________

List all brothers and sisters, or others living with the family and their relationship to the child:

|Name |Age |Sex |Relationship to child |Living in home? |Living outside home? |

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Has the student been involved in any of the following settings? If yes, indicate the dates: Foster Home ___________________________ Group Home ____________________ Correctional Facility _______________________ Psychiatric Facility _______________________

Independent Living Situation _______________________Other (specify) ___________________________________________________

MEDICAL HISTORY

Is the child currently on any medication at this time? Yes _________ No __________. If yes, list information.

|Medication |Dosage |Dispensed at |Diagnosis and Reason for Medication |

| | |Home |School | |

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List any chronic medical conditions: _________________________________________________________________________________

______________________________________________________________________________________________________________

Please explain the illness or condition and any side effects: _______________________________________________________________

______________________________________________________________________________________________________________

Name of child’s doctor __________________________________ Address __________________________________________________

Date of last physician examination ___________________________ Does the physician know of the child’s school problems? _________

Physician’s comments about school problems: _________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

Student’s Name:____________________________________

SPECIAL FACTORS

VISION: HEARING:

____No apparent problem ____No apparent problem

____Vision Examination ____Hearing Examination

(Date ______________ by whom___________) (Date ______________ by whom___________)

____Wears glasses ____Had surgery (specify ________________________age_____)

____Wears contacts ____Ear infections/frequency_____________________

____Had surgery (specify: ________________ age______) ____Hearing loss/Age of loss_____________________

GROSS AND FINE MOTOR: COMMUNICATION:

____No apparent problem ____No apparent problem

____OT or PT Examination ____Speech and Language Examination

(Date _____________ by whom____________) (Date ______________by whom____________)

____Walking, jumping, running problems ____Problems expressing thoughts

____Cutting, writing, coloring, printing problems ____Problems pronouncing words

____Other (specify _________________________________) ____Other (specify ________________________________________)

SOCIAL:

How does your child interact with other children (list any fights, play groups, friends, trouble, etc.)? ________________________________

______________________________________________________________________________________________________________

How does your child get along with adults? ____________________________________________________________________________

______________________________________________________________________________________________________________

Have you noticed any unusual social interactions? Yes____ No____ Please explain: __________________________________________

______________________________________________________________________________________________________________

SCHOOL HISTORY

What school(s) has your child attended since the last three-year evaluation? Please list: ______________________________________

_____________________________________________________________________________________________________________

______________________________________________________________________________________________________________

SCHOOL INTERVENTIONS

List any school interventions that have occurred in the last three years, such as: remediation, summer school or repeat grade.

_____________________________________________________________________________________________________________

______________________________________________________________________________________________________________

AGENCY SERVICES

List the agencies that have provided services for your child in the last three years, such as: private tutoring, counseling, community service agency, mental health agency, Department of Children and Families, court system, day treatment program, inpatient psychiatric hospital.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Do you have any other questions or concerns you want addressed in the evaluation? __________________________________________ ______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

How long has this been a concern to you? ____________________________________________________________________________

Any other information that would help us understand you child? ___________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________

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